Thinking ahead about migraine

Migraine can be a debilitating condition that dominates a person’s life. Find out how pharmacy teams can support sufferers with prevention and management advice and help them take back control

Migraine has been recorded as a condition by people as far back as Greek physician Hippocrates in 400 BC and even further back, by the ancient Egyptians in 1200 BC. But although this common ailment has been around for so long, little is known about what causes it. Nevertheless, there are ways to manage migraine and tips that pharmacy teams can share with customers to help prevent attacks.

What is migraine?

Migraine is a genetic neurological condition that affects an estimated one in seven people globally, according to The Migraine Trust. It is the third most common disease in the world, and is more prevalent than asthma, diabetes and epilepsy combined. 

In the UK, the NHS estimates that around one in every five women and one in every 15 men suffer. Migraine attacks vary in length, lasting between four and 72 hours. They can occur as infrequently as once a year or as frequently as several times a week.

There are two main types of migraine:

• Migraine without aura is the most common form. It presents as a throbbing headache, usually on one side of the head, with pain intensity ranging from moderate to severe. Some sufferers become nauseous and may vomit or have diarrhoea; they may also become sensitive to both light and sound.
• Migraine with aura has the same symptoms, but with the addition of aura – a kind of warning signal that can last for between five minutes and an hour. Aura causes visual disturbances such as flashing lights, seeing stars and blind spots. It can also lead to numbness, pins and needles-type tingling, dizziness and difficulty finding the right words. It is thought that around 10-30 per cent of migraine sufferers experience aura. 

Although the cause of migraine remains unclear, there are certain things that are known to trigger the condition, including stress, missing meals, certain foods, such as red wine and chocolate, tiredness, hormonal changes, bright lights and loud noises.

OTC management options

When it comes to managing migraine with OTC medication, there are three main things that pharmacy teams can recommend: antiemetics to treat nausea, simple analgesics (paracetamol, aspirin or ibuprofen), and triptans – considered the “gold standard” treatment for acute attacks, says Dr Katy Munro, headache specialist at the National Migraine Centre. These are available on prescription, or customers can buy a pack of two sumatriptan tablets over the counter from the pharmacy if they have previously been diagnosed with migraine.

Nausea is often present with migraine, but can be overlooked. “Often, people with migraine attacks haven’t been offered something to enhance their gastric motility,” says Dr Munro. “The problem is the stomach isn’t emptying properly, so whatever painkillers they take are only slowly absorbed because they are hanging around in the stomach. They need to be pushed on, down further into the gut, where they are more rapidly absorbed. We usually advise people to go and speak to their GP about getting a prescribed antiemetic.” Dr Munro says that over-the-counter anti-nausea tablets can also be helpful. However, she advises that people with migraine should not take codeine for pain management.

Red flag symptoms

Even if someone has experienced migraine before, they should seek urgent medical attention if they: 

• Show symptoms of weakness or paralysis in one or both arms or down one side of their face
• Have slurred speech
• Have a headache that comes on very suddenly and is extremely painful
• Have a headache alongside a fever, stiff neck, confusion, rash or seizures.

Possible alternatives

Other forms of treatment for migraine include neuromodulation devices, which use electrodes to target nerves and reduce pain.

Injections are also an option, including botox injections, glycerol nerve block injections and anti-calcitonin gene-related peptide (CGRP) monoclonal antibody injections, which are now available on the NHS. “Patients inject themselves once a month, and they have been a real game changer for some people,” says Dr Munro. “They are the first therapy that was designed specifically for migraine.”

A migraine diary is another useful tool for sufferers and can play an important role in prevention. “Migraine diaries are really important so that people can understand the patterns in terms of what might be causing a migraine attack,” says The Migraine Trust spokesperson Una Farrell. “It is also useful to record any medication they take, the impact that it’s having, how effective it is and the patterns of their migraine. Some people’s migraine attacks last an hour, others three days, so the more information and the more understanding a person has, the better it will help them manage it themselves. Also, if they go to a GP, it will help inform the GP as well.”
Signposting suggestion: Migraine Trust – Keeping a migraine diary. 

Self care advice

Pharmacy teams can provide self care advice to help people prevent and manage their migraines. 

• Diet

Having low blood sugar can cause a headache and it can be a trigger for migraine too. Some 44 per cent of people with migraine notice cravings for certain foods before an attack, especially sweet and salty foods, and carbohydrates, according to the ‘Self Care and Migraine’ survey, conducted by the National Migraine Centre in 2020. “We would always recommend to our patients to have something to eat every three to four hours,” says Dr Munro. “Preferably a low glycaemic index (GI) or slow-release energy food, so not too many carbohydrates. And to perhaps have a bedtime snack as well because sometimes people say they had their dinner at 5pm in the evening and don’t eat anything until 8:30am the next morning. That is a very long time for the brain to be hungry and it puts them a step nearer to having a migraine attack.” 

• Sleep

Getting the right amount of sleep is important, as migraine can be caused by both too little and too much sleep. “This often happens with teenagers who are having to get up at 7.30am and rush off to school and then at the weekend, they stay in bed until 12pm. Over the next coming days, they develop migraine because the brain is more irritable when there is a prolonged amount of sleep as well. Beware the lie in!” says Dr Munro.

As sleep can be a cure as well as a trigger for migraine, it’s important that sufferers pay attention to what optimum hours are best for them. This can be added to their migraine diary. 

• Exercise

Just like sleep, finding the right balance with exercise is key. “In good ways, exercise can help manage stress, but for other people, if they go from doing very little exercise to a lot, it might trigger an attack,” says Una. “It’s about building the exercise up over time so that it’s not such a shock to the body.”

The Migraine Trust advises doing moderate intensity exercise for at least 30 minutes, three times a week for a minimum of six weeks to see what effect it has. It recommends mild, regular aerobic exercises such as jogging, swimming and cycling. In the ‘Self Care and Migraine’ survey, 54 per cent of people found brisk walking the most helpful type of exercise.

• Stress

Stress can be a significant trigger for migraine, and although managing stress is not the be all and end all of migraine prevention, it can certainly help to make a difference. “If people’s stress levels are lowered, it can reduce the frequency of attacks, but not always,” says Una. “For many people, it might just help them live with migraine because it is a condition that can grind you down.”

She recommends that people practise mindfulness and stress management, perhaps by using apps, courses or local clubs. Pharmacy teams can signpost customers to the National Migraine Centre’s informative ‘Heads up’ podcast for further tips and advice.

Increasing severity

In 2020, more than half of people with migraine had more frequent attacks and a third reported their symptoms as being more severe, according to a survey conducted by The Migraine Trust.

This was attributed to stress (57 per cent), lifestyle becoming harder to manage (18 per cent) and a lack of access to treatment and management (16 per cent).

“The pandemic has had a massive impact on people’s migraine,” says The Migraine Trust spokesperson Una Farrell. “If they are working from home then they might not be sitting in the same type of chair they would in the office and that can aggravate their back, which then might trigger a migraine attack.” 

The survey also found a significant impact on access to treatment, with one in five people reporting having appointments with specialists cancelled and 15 per cent saying they were unable to book an appointment in the first place.

However, it’s not all bad news. Una says that working from home has been beneficial for some people with migraine. “They have actually found it much easier to manage their lifestyle because they could get up later, they didn’t have to go to bed so early and if they have a migraine attack then they can just go and lie down for half an hour,” she explains. 

Helping with headaches

Pharmacy teams can help to identify different types of headache so customers get the right treatment quickly.

• Tension headache

When someone complains of a “normal” everyday headache, it will usually be a tension headache. Lasting up to a few hours, tension headaches cause aching in the head and sometimes pressure behind the eyes, as well as tightening in the neck muscles. Triggers can include dehydration, tiredness, stress, poor posture, hunger and a lack of physical activity. Finding ways to de-stress, such as gentle exercise like yoga, or placing a cool flannel on the forehead or a warm flannel on the back of the neck, can also help. Painkillers such as paracetamol, ibuprofen or aspirin can be recommend if appropriate.

• Cluster headache

Cluster headaches cause severe pain. They affect around two in 1,000 people, according to the Organisation for the Understanding of Cluster Headache UK (OUCH UK). They are more common in people aged 30-40, especially among men and smokers, it adds.

They occur on one side of the head, causing a sharp piercing or burning sensation. Additional symptoms can include a red and watery eye on the side of the headache, a droopy eyelid, tightening of the pupil, facial sweating and a runny or blocked nose.

Attacks can last for up to three hours, with some people getting them as often as eight times a day. Triggers can include strong smells such as petrol or paint.

According to Colin Allen, vice chairman of OUCH UK, there are no over-the-counter treatments for cluster headache. “A formal diagnosis is crucial for effective treatment and medication regimes,” he says. “Patients who present with headache and have yet to be diagnosed should request a referral via their GP to a neurologist who specialises in headache.” 

Pharmacy teams can help signpost people to the right support. OUCH UK has an advice line number: 0800 6696824 and an email address: adviceline@ouchuk.org. 

• Medication-overuse headache

Taking certain medicines such as triptans, paracetamol and codeine too often can actually cause headaches rather than relieve them. Medication-overuse headaches are characterised by a dull pain and tend to last throughout the day, usually being more intense in the morning. 

The only way to prevent medication-overuse headache is for people to avoid taking painkillers too often. “I tend to say ‘don’t use simple painkillers more than 14 days in a month and don’t use triptans on more than eight days in a month’,” says Dr Katy Munro, headache specialist at the National Migraine Centre.

Stopping taking certian painkillers can cause withdrawal symptoms, which vary in severity and length. “With codeine, the withdrawal headaches can go on for six months or more,” explains Dr Munro. “With triptans, they normally settle down within four to six weeks. So that’s one of the many reasons that we say ‘please don’t have codeine for your migraine’. If people have one migraine a year and they take codeine, they’ll probably be fine, but so often they have more frequent migraine and then codeine builds up and it’s ineffective.”